Kaiser Health News

JUPITER, Florida — She didn’t want to spend the rest of her days seeing doctors, the 91-year-old woman confessed to Dr. Kevin Newfield as he treated a deep wound on her arm.

“You don’t have to, but you have to tell me what you do want,” Newfield replied.

“I’m not afraid of dying. I’m afraid of being 106,” she told the surgeon and her daughter, who was in the room with them.

The woman’s spontaneous admission in Newfield’s south Florida office that January day triggered a 20-minute discussion about living wills, hospice and other end-of-life issues, Newfield said.

An orthopedic surgeon who sometimes performs amputations, Newfield is comfortable having those conversations.

Many doctors are not, but a Medicare policy, known as advance care planning, that took effect in January could help change that.

Physicians can now bill Medicare $86 for an office-based, end-of-life counseling session with a patient for as long as 30 minutes. Medicare has set no rules on what doctors must discuss during those sessions. Patients can seek guidance on completing advance directives stating if or when they want life support measures such as ventilators and feeding tubes, and how to appoint a family member or friend to make medical decisions on their behalf if they cannot, for instance.

The new policy reflects Americans’ growing interest in planning the last stage of their lives when they may be unable to make their wishes known.

In 2014, the Institute of Medicine, an influential panel of experts, found that the nation’s health system was not adequately dealing with end-of-life care, and among its recommendations was that insurers pay providers for advance care planning discussions.

Last September, a Kaiser Family Foundation poll found 89 percent of the public said that doctors should discuss end-of-life care issues with their patients, though just 17 percent of Americans — and 34 percent of people 75 and older — said that they have had such conversations. (KHN is an editorially independent program of the foundation.)

Under the new Medicare policy, doctors can give end-of-life advice during a senior’s annual wellness visit or in a routine office visit. Nurse practitioners and physician assistants can also get paid for having the talks. Counseling can also occur in hospitals.

“For doctors already providing this counseling the payment is an added benefit and for doctors on the fence about talking about the issue with patients, this may be enough to inspire them to try it,” said Paul Malley, president of Aging with Dignity, a national advocacy group based in Tallahassee, Florida.

Newfield, the Florida surgeon, is less optimistic. He said he doesn’t think the money will cause him to initiate more end-of-life discussions — and that doctors who weren’t doing them before now are unlikely to start. After all, said Newfield, doctors make money by keeping people alive.

The payment idea was first floated in 2009, as part of the congressional debate over the Affordable Care Act. Back then, a proposal to have Medicare pay for such discussions sparked political controversy and fueled concern that they would lead to so-called death panels that could influence decisions to avoid medical care. The proposal was quickly dropped.

Medicare’s policy now has broad support from health providers and patient groups, but neither physicians nor the American Medical Association foresee a surge in end-of-life planning among Medicare’s more than 50 million enrollees. The AMA, which supports the reimbursement, estimates Medicare will pay for fewer than 50,000 counseling sessions in 2016.

The numbers may well be held back by the small reimbursement rate for half an hour of counseling, but another obstacle rests with doctors themselves. Many are not trained to offer such advice or they are uncomfortable talking about it with patients.

“Just The First Step,” the journal Health Affairs headlined an article about Medicare’s new policy in its March issue.

“The perception that lack of training could be a major stumbling block to the greater implementation of advance care planning is widely shared,” wrote David Tuller, a lecturer at the University of California, Berkeley, School of Public Health.

“A lot depends on how you deliver the message and how you go about it,” said Dr. Jay Poonkasem, who specializes in palliative care in Clearwater, Florida.

“We will see more of this counseling, but only if doctors feel more comfortable and are trained in the right way to handle talks about end-of-life and advance care planning.”

Medical schools such as the Cleveland Clinic Lerner College of Medicine and the University of California, San Francisco, have recently begun expanding training on the subject.

At UCSF, all medical students are taught how to conduct advance care planning discussions and educational programs also exist for residents, nurses and other physicians at the hospital.

“This kind of training is crucial — one of the things that gets in the way of understanding and using patient preferences is that clinicians are often uncomfortable having these challenging conversations,” said Dr. Robert Wachter, professor and interim chair of UCSF’s Department of Medicine. “The issue of end-of-life conversations is so compelling and fraught — teaching it also allows us to teach about more general communication skills.”

Some doctors admit they could do better.

Dr. Scott Dunn, a family physician in Sandpoint, Idaho, said he regrets not having done more recently to help a 76-year-old patient avoid spending his final weeks in intensive care, connected to machines breathing for him and feeding him. That meant the patient may have needlessly suffered and cost the health system tens of thousands of extra dollars, he said.

“I wish I had taken the time months earlier to have that end-of-life discussion, but I did not,” he said.

Dunn said the incentive payment will entice him to have more such discussions with patients, but they won’t become routine in his practice. “Medicare pays us more to do other stuff.”

Michael Guarino came to a different view after watching his elderly father die last year, weeks after he became unable to move or talk. Guarino decided then that the 800-physician organization of which he is executive director — the Independent Physician Association of Nassau/Suffolk Counties in New York — would include end-of-life discussions for all adult patients.

To guide those discussions, the association’s physicians and nurses use a 12-page booklet called Five Wishes, which outlines how patients can designate someone to make decisions on their behalf if they become unable, as well as choose what treatment they want, if any, at the end of their life.

Dr. John Meigs, Jr., a family doctor in Centreville, Alabama, and president-elect of the American Academy of Family Physicians, said he sees value in doctors helping patients prepare for death.

Last July, a stroke left a 95-year-old nursing home patient of his with difficulty speaking and swallowing. The woman’s daughter questioned Meigs’ decision not to give the patient a feeding tube. Meigs reassured the daughter that her mother had made clear she didn’t want that in many talks with him and in her advance directives.

No heroic measures were made and the woman died a few days later.

Read original article – March 16, 2016
Doctors Ponder Delicate Talks As Medicare Pays For End-Of-Life Counsel

Very young children who endure neglect, abuse and dysfunctional home lives go on to struggle as kindergartners, leaving them at risk for more difficult years as adolescents and adults, a new study finds.

Adverse childhood experiences before age 5 were linked with poor academic and behavioral performance in kindergarten, said researchers who examined a sample of about 1,000 urban children. Their study was reported in the journal Pediatrics this month.

“Relative to children with no ACEs, children who experienced ACEs had increased odds of having below-average academic skills including poor literacy skills, as well as attention problems, social problems, and aggression, placing them at significant risk for poor school achievement, which is associated with poor health,” the authors said.

The adverse experiences included varieties of maltreatment — psychological, physical or sexual abuse or neglect — as well as household dysfunction — such as maternal depression, substance abuse, incarceration or violence toward the mother.

Forty-five percent of the children in the study had no adverse experiences, 27 percent had one, 16 percent had two and 12 percent had three or more.

The researchers from children’s hospitals in New Jersey and Philadelphia analyzed data from a national group of participants in the Fragile Families and Child Wellbeing Study, drawing on the study’s follow-up interviews with mothers five years after their child’s birth and data on teacher-reported school performance near the end of the child’s kindergarten year.

Teachers rated about a quarter of the children below-average for literacy and math skills. Children with more adverse experiences generally showed worse academic, literary and behavior outcomes, the study said.

Dr. Manuel Jimenez, the study’s lead author and assistant professor of pediatrics, family medicine and community health at Rutgers Robert Wood Johnson Medical School, said that when he sees children having academic or behavioral difficulties, there are often deeper problems that originate at home. The analysis adds to a growing body of research that shows behaviors that start in early childhood can lead to dropping out of school, committing crimes and poor health in adulthood.

“This affects children’s ability to do well in school, the work world and the likelihood in ending up with trouble with the law or fitting into society. All those things come together and it’s a vicious cycle that repeats itself. And if we don’t intervene, then they evolve in less healthy ways and that repeats for the next generation,” said Debra Ness, president of the National Partnership for Women & Families.

Read original article – February 29, 2016
Study Links Kindergartners’ Stumbles With Rocky Home Lives

April Pearce is in the middle of her freshman year at UCLA, settling into life away from home for the first time. But instead of thinking about dorm food or exams, the 19-year-old is focused on something a little more abstract: old age.

That’s because of a unique course Pearce is taking called Frontiers in Human Aging, designed to teach first-year college students what it means to get old — physically, emotionally and financially.

Pearce said that before, she barely noticed elderly people when she passed them on the street. Since being in the aging class, seeing them fills her mind with questions: Do they live alone? Will they develop dementia? Do they interact with anyone apart from relatives?

“It’s weird, I know,” she said. “But before, I didn’t have any knowledge really about aging. I didn’t even interact with any older people except for my grandmother. Now I’m learning so much.”

In addition to teaching students about aging, the professors have another goal in mind: inspiring them to pursue careers working with the elderly.

With more than 10,000 baby boomers turning 65 every day, there is a growing need, said Rita Effros, a professor at UCLA’s David Geffen School of Medicine who teaches both undergraduates and medical students.

People over 65 represented about 14 percent of the U.S. population in 2013, and that figure is expected to increase to nearly 22 percent by 2040. During that same time period, the number of people over 85 is expected to triple.

And jobs working with the elderly won’t just be in medicine but also in social work, psychiatry, technology and law, Effros said.

“We try to make it clear that aging is going to be big business,” she said. “Whatever their interests are, they should think about serving the elderly.” The strategy seems to be working on many of the students, including Pearce. She started UCLA in the fall wanting to be a veterinarian and now is thinking about becoming a geriatrician.

The class, which has about 120 students, is taught jointly by Effros, an immunologist, Paul Hsu, an epidemiologist, and Lené Levy-Storms, a social welfare professor. UCLA started offering the course in 2001, but the professors said it is becoming increasingly important.

Throughout the year, students hear lectures about anxiety, genetics and dementia. They discuss ageism and read about Social Security. They stage debates on assisted suicide and watch films about growing old.

The course lasts from September to June, and students can go on to take other classes about aging, including ones that focus on diversity or public policy.

Effros said she wants the students to understand people don’t suddenly become old. Rather, the aging process starts when they are conceived. “A lot of life habits and choices they make as college students can affect them decades later,” she said.

During one guest lecture, UCLA medical school professor David Reuben explained how geriatricians evaluate patients and told students about some of the most common problems older people face — dementia, falls, sensory impairment.

He also described how the students’ own lives will change as they age. Instead of traveling the world, older people eventually become unable to travel out of their own bedrooms.

One student raised his hand and said being a geriatrician sounded gratifying, but also seemed heartbreaking. “You watch so many people decline … how do you handle that?”

Reuben responded that he does get sad and he does cry. “Nobody lives forever and nobody should live forever,” he said. “Death is part of the human experience.”

Michael Margolis, 17, said being in the class has made him think for the first time about his own mortality. “It’s not something we typically think about as teenagers,” he said.

One requirement of the class is that students spend a total of 20 hours volunteering with seniors.

Just after the New Year, the students gathered in a large room on campus to meet representatives from several agencies that serve the elderly. Andres Gonzalez, a director at St. Barnabas Senior Center in Hollywood, told the students they could teach technology classes to active seniors or help deliver meals to homebound ones.

“Even that short interaction becomes very meaningful to the seniors,” Gonzalez said. “You might be the only person they see that day. And they get even more excited seeing younger people.”

April Pearce was assigned to WISE & Healthy Agin

g, which runs an adult day service center for seniors with dementia. Catherine Jonas, who previously directed of the center, said the students bring a lot of energy to the center, and they often lead bingo games and exercises. They also have lengthy conversations with the seniors.

“What the older adults need is that dialogue,” Jonas said. And for students interested in learning about dementia, interacting with people affected by it “is so much better than what they get from a book,” she added.

One morning early last month, the center was decorated for Valentine’s Day, with red and white streamers and cut-out hearts hanging from the ceiling.

One of the student volunteers, Julia Gierasimow, led the group as they rolled their shoulders, stretched their legs and tried to touch their toes. Gierasimow, who is also considering a career in geriatrics, said all the seniors she’s met so far have interesting life stories.

“I don’t know if they remember me from week to week … but they are very friendly,” she said. “As bad as their dementia may be, they still give you a hug.”

After the physical exercises, Pearce sat in a chair in the middle of the room, picked up a microphone and commenced with the mind exercises she’s led each visit. Today’s activity: a quiz game about football.

“Which team won the first Super Bowl ever?” she asked, smiling.

Several of the seniors shrugged. One man, 76-year-old Tracy Williams, yelled out the right answer: “Green Bay Packers!”

Williams, retired from the Air Force, said he enjoys when the college students come to visit — even though he never would have done the same at their age. “When I was young, I didn’t want to even be near an old person,” he recalled.

Pearce said that in just a few weeks of volunteering, she is becoming more patient and is learning how to talk to people with dementia. “If they say it’s Tuesday, you’re supposed to go with it,” she explained.

Pearce said the class has given her a new perspective on her own life, too. She is trying to eat less fast food and exercise more. And she tries not to worry so much about things like not doing well on an exam. “I am going to have health problems later if I let the stress get to me,” she said.

Pearce is also seeing her grandmother in a new light, especially after doing an in-depth interview with her for a class assignment.

She said she learned that her grandma had undergone hip replacement surgery, a kidney transplant, and treatment for cancer. She also discovered her grandma had loved to dance when she was younger, and was popular with the boys.

“I had never really thought about my grandmother as a young woman,” Pearce said. “This class is making me appreciate her more.”

Blue Shield of California Foundation helps fund KHN coverage in California.

Read original article – March 2, 2016
UCLA Freshmen Learn About Growing Old

A bad bout of pneumonia sent Bruce Anderson to Sutter Medical Center in Sacramento last May. As soon as he recovered, hospital staff tried to return him to the nursing home where he had been living for four years.

But the home refused to readmit him, even after being ordered to do so by the state. Nearly nine months later, Anderson, 66, is still in the hospital.

“I’m frustrated,” said his daughter, Sara Anderson. “You cannot just dump someone in the hospital.”

Anderson said her father, who has a brain injury that causes dementia-like symptoms, is confined to the hospital bed and frequently given anti-psychotic medications. She believes the nursing home, Norwood Pines Alzheimer’s Care Center, refused to readmit him because it wanted to make room for more lucrative and less burdensome residents.

“I didn’t have any question this was about money,” she said.

Bruce Anderson is the victim of a flawed readmission system for patients who want to return to their nursing homes after spending time in the hospital.

Nursing home residents are entitled to hearings under federal law to determine whether they should be readmitted after hospitalization. The state Department of Health Care Services holds the administrative hearings, but has said it is not responsible for enforcing the rulings.

But the state Department of Public Health, which oversees nursing homes, neglects to enforce the rulings and sometimes disagrees with them, according to advocates and court documents.

That leaves residents like Anderson, who won his hearing in July, with little recourse — and not many places to go. And since many nursing home residents have publicly-funded insurance, it means taxpayers are on the hook for hospital stays long after the patients are ready for discharge.

“Federal and state law have created a complicated and expensive process to ensure residents are not abandoned by their nursing homes,” said Tony Chicotel, a staff attorney at the nonprofit California Advocates for Nursing Home Reform. “It fundamentally doesn’t work.”

Chicotel said the outcome is “profoundly problematic” — vulnerable residents are abandoned by the nursing homes and then by the state.

Bruce Anderson, two other displaced nursing home residents and California Advocates for Nursing Home Reform are plaintiffs in a pending lawsuit against the California Health and Human Services agency.

Their suit, filed in federal court in San Francisco last November, alleges that the state is violating U.S. laws aimed at protecting nursing home residents from being “dumped” at hospitals. A hearing on the case is scheduled for next month.

Attorney Matthew Borden, who is representing the plaintiffs, said he wants the federal court to require California to establish a hearing process that complies with federal law and to enforce the rulings.

“We are not asking for the moon,” he said. “What is the point of a hearing if no one is going to enforce it? … This illustrates how futile this process is.”

The state’s Health and Human Services agency, which oversees both health departments involved, declined to comment, as did its attorneys at the California Department of Justice.

The defense lawyers filed a motion to dismiss the case, however, arguing that the plaintiffs haven’t presented evidence of a “systemic problem” with regard to residents who are not readmitted to facilities after winning their administrative hearings.

The defense motion also lays out several ways in which state officials could enforce administrative hearing orders, including civil penalties against nursing homes. But Chicotel, of California Advocates for Nursing Home Reform, said the state doesn’t avail itself of  the enforcement mechanisms.

Deborah Pacyna, public affairs director of the California Association of Health Facilities, the trade association for nursing homes, said facilities can’t always take residents back after hospitalization — even if the administrative ruling is in the resident’s favor.

For example, nursing homes are prohibited by law from taking residents if they are dangers to themselves or others — or if the facility can’t provide adequate care for them, Pacyna said.

She said Bruce Anderson did pose a danger — that he had assaulted a staff member and law enforcement officers. The nursing home said in the administrative hearing that it believed Anderson would be better off in a psychiatric facility, according to the ruling.

“This is not about money,” she said. “This is about patient safety … The nursing home has to take into account the safety of the entire population.”

Regardless of motive, the refusal of nursing homes to readmit residents can put hospitals in a difficult situation. Patients can linger in the hospital for a year or more as staff members search for places that can accommodate their serious physical or behavioral needs, said Pat Blaisdell, vice president for the continuum of care at the California Hospital Association.

“It’s a major problem,” she said, noting that on any given day there are a few hundred people in hospital beds around the state who shouldn’t be there. That takes up valuable beds, staffing time and money that would be better spent on patients who genuinely need to be there.

Medi-Cal pays hospitals about $400 a day for these patients — far less than what it takes to provide care for them, Blaisdell said. Nursing homes also receive meager reimbursement from Medi-Cal, which Blaisdell said she believes is likely a factor when they decide not to readmit residents.

Whatever the reason, keeping patients hospitalized when they don’t need to be is medically bad for them, she said.

John Wilson, 61, is another one of the other plaintiffs in the lawsuit. He spent seven months at St. John’s Pleasant Valley Hospital in Camarillo after the hospital’s parent company, which owns the skilled nursing unit where he had resided, refused to readmit him to it. Wilson has ALS, a degenerative neurological disorder commonly known as Lou Gehrig’s disease, and he needs a ventilator to breathe.

Wilson’s son, Jeremy Wilson, said that in the past his father had gone to the hospital frequently for pneumonia, skin infections and other ailments, and each time the skilled nursing unit took him back. But last April, after Wilson got a bacterial infection and ended up in the intensive care unit, a social worker said he would not be accepted back into the nursing facility.

The family appealed the decision, and won its case in an administrative readmission hearing. But the facility still refused to readmit Wilson, his son said.

Jeremy Wilson said he was angry that the nursing home didn’t comply with the order — and that the state didn’t do anything about it. But after he pushed for months, the nursing home finally allowed his father to return, he said.

“He was basically in a jail for seven months,” the son said. “He couldn’t get in a wheelchair and go down into the garden. He was literally stuck in the room, and from a psychological standpoint, it took a great toll on him.”

Sara Anderson said she is still trying to get her father out of Sutter Medical Center in Sacramento. She, too, sees the toll it is taking on him. He has grown weaker and he misses his home at Norwood Pines — and playing bingo with the other residents, she said.

Anderson said the hospital staff is nice to him and he is receiving good care, but he really needs to be in a skilled nursing facility — not an acute care hospital.

She worries that it still may be a long time before her father is discharged, and that when he is, he will be sent someplace far from her home in San Joaquin County. Finding a place for him is very difficult, she said. “Places do not want to take someone like him … He is a hard sell.”

Beyond her father’s situation, Anderson said she wants the state to fix the way it handles nursing home readmission disputes. “This suit is really for the next family whose loved one gets dumped in the hospital,” she said.

Disclosure: Blue Shield of California Foundation helps fund KHN coverage in California.

Read original article – February 26, 2016
The Agonizing Limbo Of Abandoned Nursing Home Residents

A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, North Carolina, it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable. The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed.

Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.

“It was kind of scary for a while,” Murphy remembered. But with Murphy and two other family physicians trained in obstetrics as well as experienced nurses staffing the 25-bed hospital’s labor and delivery unit, the situation was manageable, and both mother and baby were fine.

Things are different now. Alleghany hospital — like a growing number of rural hospitals — has shuttered its labor and delivery unit, and pregnant women have to travel either to Winston-Salem or to Galax, Virginia, about 30 minutes away by car, weather permitting.

“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, said Murphy, who teaches at the Cabarrus Family Medicine Residency Program in Concord, North Carolina. (Although not essential, women typically see the physician they expect will handle their delivery for prenatal care.)

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

“The fact that closures continue happening — over time that means the nearest hospital gets further and further away,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who coauthored the study published in the January issue of Health Services Research.

There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

“A labor and delivery unit is functionally no different than an intensive care unit,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. Staffing levels are high in obstetrics, often one nurse for every patient, and the rooms are cluttered with monitors, infusion pumps and other equipment.

It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and rely instead on local family physicians, but it can be difficult to get enough to fully provide services for a hospital, too. Nurses with obstetrics experience also can be scarce.

Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be difficult because insurance payments are often low. Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, said Kozhimannil. Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she said.

Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.

Encouraging medical professionals to move to rural areas is key, they say. A bipartisan billintroduced in Congress last year, for example, would require the federal government to designate maternity care health professional shortage areas. Such designations exist for primary care, mental health and dental care. The National Health Services Corps awardsscholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage area. Once they get to a community and put down some roots, the hope is they’ll stay.

Expanding the use of midwives and birthing centers could be cost effective since they are generally less expensive than physicians and hospital obstetric units. Although birthing centers and home births are on the rise, more than 98 percent of the 4 million babies that were born in 2014 made their arrival at a hospital.

“You can deal with lower volume and still be sustainable,” said Shah.

“Finding strength in numbers, small rural hospitals are increasingly banding together to share resources, said Kozhimannil. For example, since it’s difficult to keep rural staff trained in rare complications, small rural hospitals sometimes pool resources to buy a mobile simulation unit to train people on handling postpartum hemorrhage, the leading cause of maternal mortality.

Kozhimannil sees great opportunity in the ongoing national dialogue about health reform but says much of the research to date has focused on reforming health care in urban settings.

“That’s why it’s crucial to have rural people at the table,” she said.

Read original article
As Rural Hospitals Struggle, Some Opt To Close Labor And Delivery Units

Ask David Ross to describe an average day on the job. He says it doesn’t exist.

Ross is a violence intervention specialist at the University of Maryland Medical Center. Though he isn’t a doctor, he’s been working at the hospital as part of its Violence Prevention Program for close to 10 years. His team works with patients who are victims of violent injuries — stabbings, gunshots or physical assaults — and who physicians flag as candidates for the program’s assistance.

His challenge is to figure out the factors in their lives that put them at risk of violence. The work he does is time-consuming, and the relationships he builds with these patients can last months and even years.

Do you feel safe at home? Do you have health insurance? A high school diploma? A stable job? Having health insurance or a diploma is no guarantee against violence, but Ross and his colleagues ask such questions to help the team connect patients with programs that might improve their lives and insulate them from the violence that put them in the hospital.

“Some days, it can be emotional. Or it can be gratifying,” Ross said. “I spoke to a patient the other day, and he almost had me crying.”

Sometimes that kind of emotion comes from the devastating things patients have seen, whether it’s the result of a dysfunctional living situation, substance abuse, poverty or other social ills. Other times, it’s because “you thought you made progress — and then there’s a setback.”

Maryland is a pioneer in this type of coordinated effort, having launched its anti-violence program in 1998. Now, about 30 hospitals across the country — from the Children’s Hospital of Philadelphia to the University of Rochester Medical Center in New York — have developed similar initiatives. They follow Maryland’s “wraparound” approach, which involves following up with patients after they leave the hospital, and providing medical and social support to keep them out of harm’s way — by, for example, getting them into drug rehab or education classes for people who have not finished high school. The hospitals are acting on the notion that keeping violent injury from recurring will ultimately reduce their expenses and improve people’s long-term health. In other words, they increasingly view violence prevention programs as both good medicine and good business.

On this particular day, Ross visited seven hospital patients who were being treated for violent injuries. Ross’s job isn’t just to identify the trouble spots in a patient’s life; it also involves moving with the person through the legal and medical systems, sometimes acting as an advocate. The day before, for instance, he had accompanied a mentally ill client to court to make sure the man’s condition was understood by authorities. On such days, he dresses in a suit instead of his hospital uniform: pink scrubs, an outfit that shows that while he doesn’t stitch wounds or prescribe pills, he’s part of a team dedicated to keeping patients healthy.

As experts increasingly view violence as a medical concern, hospitals see it as an opportunity. “There’s been a groundswell of professionals understanding that this is a public health issue,” said Rochelle Dicker, a trauma surgeon and professor at the University of California, San Francisco, who directs the UCSF Medical Center’s violence prevention program.

And the 2010 federal health law supports that interest. It says nonprofit hospitals have to work harder if they want to maintain their tax-exempt status: Among other requirements, they have to formally measure their surrounding community’s health needs at least every three years and implement a strategy to address them.

To this end, a growing number of hospitals, especially those located in areas with high rates of violent crime, are partnering with local organizations to try to reduce neighborhood violence, said Jonathan Purtle, an assistant professor at Drexel University who researches hospitals and violence prevention.

The Department of Justice has been supportive, too. In a 2012 report, it recommended that hospitals become more involved in violence prevention, through counseling patients directly or connecting them with education, gang diversion programs, substance abuse treatment and other social services.

Research shows that, if someone comes in suffering from a gunshot or stab wound and then, after leaving the hospital, returns to the same environment, there are good odds they will be back in the emergency department. In addition, trends and anecdotal evidence suggest people at higher risk for violent injury are likely to face issues such as domestic violence, mental illness or substance abuse. They also often deal with other stressors, like poverty or bad housing. These challenges can result in health problems including lead poisoning and poor nutrition, which the hospital can work to address. Even if they can’t change, for instance, a neighborhood’s crime rate or drug culture, they can help someone get into rehab or find somewhere new to live.

Much of the growth in such hospital interventions has happened in the past five years, Dicker said.

“It’s becoming a more established understanding that this kind of violence is preventable,” said Rebecca Cunningham, an emergency medicine professor at the University of Michigan and associate director of its youth violence prevention center. “And we can have programs that can prevent it, and the hospital and emergency department are really critical locations for this.”

Michigan’s center doesn’t do that same level of outreach and case management as Maryland’s. All patients between the ages of 14 and 20 and from neighborhoods where violence is more prevalent are approached for a counseling session — what Cunningham called a “preventive” intervention.

So far, there isn’t much research measuring these programs’ effectiveness. But the findings available show promise. UCSF found that people who had come to the hospital with a gunshot or stab wound and then participated in the intervention program were far less likely to get injured again after leaving. The number of patients returning with another violent injury dropped from 16 percent to 4.5 percent. And in a paper published last year, researchers estimated that program would save the hospital half a million dollars annually.

That’s crucial. “It’s very important to be able to talk about cost effectiveness” as hospitals look to curb unnecessary expenses, Dicker said.

The University of Maryland‘s statistics are similarly encouraging. Research found victims of violent injury who went through the program were 83 percent less likely to return because of another violent event when compared with those who didn’t participate, said Tara Reed Carlson, who directs the university’s Center for Injury Prevention and Policy. Those who had participated in the program were more likely to have a job and less likely to be involved in criminal activity.

Ross said the work he does — and the change he sees — underscores the value of intensive outreach. The before-and-after contrast is striking. “I’m talking about young guys who haven’t had any guidance,” he said. “That’s rewarding.”

Often, he said, patients stop by to visit, years after they’ve gone through the program. They share new successes, like buying a home or getting married.

“It makes you feel good,” he said. “You’re doing something that’s needed.”

Read original article – January 20, 2016
For Hospitals, Treating Violence Beyond The ER Is Good Medicine And Good Business